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A great service...if only there were no patients
[ by Niall Hunter, Editor www.irishhealth.com]
An old joke often told about our beloved health service is that it would be more efficiently run if it didn't have to treat any patients.
This cynical maxim is starting to have a ring of truth about it as the Troika continues to dictate health pollcy and the HSE is constantly exhorted to do more and more with less and less. It is now facing what could be its biggest financial crisis.
The way things are going, the HSE could well turn into a bureaucratic fantasy land of report-writing and target- setting about services that will never be delivered - if it isn't this already.
Theory always sounds better than practice when it comes to funding and planning healthcare in Ireland. In truth it has always been pretty much that way, through boom times and bust.
The depressing same old story, only worse, is evident from a quick look at the HSE's recent performance statistics.
They show that our ageing and sicker population has a nasty habit of turning up in increasing numbers at hospitals to be treated, at great expense to the public purse. People can be so inconsiderate.
And there is little sign yet of Health Minister James Reilly's alternative healthcare world where 'Morris Minor' patients don't go to 'Ferrari' garages to be fixed, and instead are treated more cheaply locally, preferably without a major hospital stay at all.
But no, these ingrates just keep on turning up at big hard-pressed hospitals demanding to be treated. Sometimes they are treated on the floor of emergency departments, But then, beggars can't be choosers.
These patients may well have done a bit of research and would have quickly found out that most of the grandiose alternative care pathway plans, clinical programmes and waiting list initiatives are beginning to look more and more like window-dressing.
They are only serving to mask the defects in a health service that is at this stage chronically bereft of funds and has long since lost any real capacity to deliver accessible and timely care to swathes of the population. Welcome to the wonderful world of austerity.
And, in another worrying and slightly Kafkaesque development, it appears that hospitals will now be penalised (which ultimately means patients will be penalised) for recently doing what Health Minister James Reilly told them to do-reduce ED trolley waits and treatment waiting lists.
The latest HSE performance stats revealed at the Oireachtas Health Committee show that the HSE was in the red to the tune of €197.3 million at the end of April and hospitals were €106.2 million over budget. These are pretty scary figures, but perhaps not surprising.
At the launch of the HSE's service plan for 2012, back in January, CEO Cathal Magee projected that with major budgetary cuts, hospital activity would be reduced this year by around 3%, but admitted that hospitals would be severely challenged to deliver services within their budgets.
He appears to have been right about one of these things anyway - many major hospitals are now running at 15% or more over their budgets less then half way through 2012. Limerick Regional is €9 million in the red, Beaumont €8 million, Tallaght €7.5 million.
Hospitals have been financially on the back foot since the start of the year in any case, carrying over deficits of €130 million from last year.
Far from hospital activity reducing, elective admissions are up 5.1% in the first four months of 2012, inpatient discharges are 2% up, as are day case rates. Emergency admissions are up 1.4%. So hospitals are stubbornly insisting on continuing to treat patients. The nerve.
The HSE notes that hospital activity levels for the first four months of this year are way over 'targets' set for them back in January, and says this is not 'financially sustainable'.
To the untrained eye, this begs the question as to how and why these targets are set.
Our patient population is getting older, is living longer and as people live longer they tend to have more and more things wrong with them. This puts pressure on public hospitals, as does the increasing numbers giving up their private insurance and relying on the public system, as does the lack of alternative community accommodation for 'delayed discharge' patients in acute beds.
So it is simply a pipe dream to expect hospitals to blithely reduce their activity levels and meet paper targets in the face of this increasing demands on services and in the absence, despite the Minister's promises, of alternative care pathways to regular hospital admission and lengthy stays.
How can hospitals 'reduce activity' if patients keep turning up to be admitted in the absence of these much-vaunted 'virtual reality' services, which we are constantly being told are about to bear fruit?
Well, one popular way of reducing activity is to close beds and theatres and put more patients on waiting lists, which is now the most likely scenario. However, when it comes to ED attendees, you can't simply turn them away, so as the cuts bite, we can expect even more pressure on that part of the hospital system.
And here's another conundrum. A recent HSE performance report states: "this increased (hospital) activity can be attributed to a number of factors which include a general increase in demand for hospital services (who'd have thunk it?), hospitals moving patients through the system as they respond to ED waiting time targets, as well as delivering an increased number of elective procedures."
So, let's get this straight. James Reilly tells hospitals to get patients off ED trolleys and treat more patients on waiting lists. They make some progress on this, and are then told by the HSE that they really shouldn't have been doing this at all at all and will now have to treat fewer patients to stay within targets and budgets.
A definition of what Catch 22 might be apposite here - "a situation in which a desired outcome or solution is impossible to attain because of a set of inherently illogical rules".
And there are more 'challenges' along the way if further cuts are to be made to get hospitals in line with their targets and budgets. Any reductions in activity are bound to adversely affect plans to further reduce ED waits and treatment waiting lists.
Even the improvements in these areas to date, under James Reilly's Special Delivery Unit, have only been qualified ones.
With hospital activity levels due to be cut, it is difficult to see how trolley numbers and waiting lists will see further improvements.
Remember, the target is that by the end of the year no-one should be waiting more than nine hours for admission through hospital EDs. At present, less than two-thirds of patients are meeting this timeline and in some hospitals the figure is only between 13% and 30%.
Also, in what could prove to be a very tall order for many hospitals, the Minister had said no patient should be waiting more than nine months on a treatment waiting list by the end of September. Currently there are just under 4,000 adult patients in this category, with new patients coming on to waiting lists all the time.
But can the health service not just trim off some non-essential fat and avoid hitting patient care?
Well, that's a bit complicated.
The HSE, back in January, warned that following major savings achieved in recent years, the scope for further efficiency and procurement savings this year that do not directly affect frontline care would be limited.
Well, the Minister, somewhat alarmed at the deficit the HSE has run up to date, has now told it that in order to make savings and avoid frontline care cuts, it would have to deal with its massive €800 million bill for spending on items like overtime, allowances, and premium pay rates.
There are two issues here. Firstly, why is the Minister 'telling the HSE to get its books in order'? Effectively, he is the HSE, having taken direct control of the health executive in the run up to its abolition and having put six Department of Health representatives on its 12 member board.
The days when a Minister for Health can play to the gallery by intimating that a quasi-independent HSE has lost the run of itself are long gone.
The second issue here, and it is a related one, is that those involved in the day-to-day management of the HSE can do little to effect a reduction in overtime, allowances etc.
Largely, decisions to be made on this, whether we like it or not, are related to contractual and Croke Park Agreement issues which are ultimately up to the Government, and not HSE management, to make a call on.
In any case, much of the bills for overtime and agency pay rates, however wasteful they may seem, have been run up to compensate for staffing deficits in certain areas.
The main message from a casual reading of the HSE's current financial report card is that the health service has given up the pretence of having adequate resources to provide equitable and accessible care to everyone, in spite of the Minister's recent initiatives.
For some time now the emphasis has been on managing deficits and targets, and not patients. And there's little sign of this changing in the foreseeable future.
|broken1 Posted: 29/06/2012 01:35|
We have an incredible health service, i mean just ludicrous.
Firstly never having worked i manage to hold a public medical card and always had a private health insurance VHI.
But now so confused about the divide surely a consultant you see in his private clinic, always being a private consultant to you, cannot ask a registrar to treat you? i need this clarified for this is what is happening as i speak as an inpatient. my Private consultant is on holidays.
not only that, whilst on the subject, do you think the consultants can communicate with you? i mean actually speak to you? talk as equal, tell you what your disease is? do you think that they can actually have time for you?
eg...i have not the time to be filling out prescriptions (again private consultant in a private consultation)! well tell me please, who fills them out? wonderful. in hospital tonight and legging it out of here before i end in a hospital of a different persuasion. my health service will kill me off and that i can guarantee.
|Tigh Posted: 06/07/2012 02:20|
In relation to the above heading; "A great service, if only, there was no patients" - ? The Health Service was a great service in the late 1970's and early 1980's, when there were smaller Hospitals, such as Mercers, Adelaide, Meath, Baggot Street, Sir Patrick Dunns, etc, etc. I had reason to attend St James Hospital in 2005, in the middle of the Boom in Ireland, and all the corridors in St James were full of patients.... So...it makes one ponder...Boom or Bust, patients lay on trolleys, no matter what money is pumped into the health service, it does not reach patient care.
|Tigh Posted: 07/07/2012 01:07|
I did leave a comment on this article last night, for some reason, it's been deleted.
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